Category: Hair Loss Causes

Hello, I have a curious question regarding the medication finasteride for male pattern baldness. I visit your balding blog website, and noticed how amazing and smart you are when it comes to propecia. I have a question

Im curious when the testosterone increases from finasteride if it can speed up hairloss in the frontal area? So propecia could in theory speed up frontal hairloss while slowing down vertex/crown hairloss? Propecia also permanently increases receptor areas for dht? So in reality propecia could make hairloss worse it is possible?

I do not believe you analysis is correct. DHT blocks the 5 alpha reductase enzyme production which causes the hair loss in genetically prone men.

I am finding that there is a trickle of these types of questions. Propecia (finasteride) is prescribed for slowing down genetic androgenic hair loss. It does not cause more hair loss. I do not know why there is a belief that testosterone causes frontal hair loss. On men who take finasteride, they still produce healthy amounts of testosterone. Sometime, the testosterone levels increase when a person is on the drug finasteride.

I am 55 years old and started working out for the first time in my life a couple of years ago. I want to be healthier and found that my testosterone levels were in the low normal range. I had a full head of hair before I started to think healthy. I take supplements for working out to stay healthy, but I have been losing my hair for the past couple of years. If I am healthier, why would I be losing my hair?

We lose hair for a series of reasons. If you were mal-nourished or rapidly losing weight, you might precipitate your genetic balding pattern which could have been silent before you started working out. Good nutrition is important, but if your supplements contain any synthetic steroids (I do not know if they do), that would induce acceleration of your genetic hair loss pattern. Hair loss in men is fundamentally genetic and although some men do not ‘express’ their balding pattern (express is a genetic term), taking any form of steroids could be enough to bring on your genetic balding pattern.

I would like to clearly state that exercising does not cause hair loss. Natural over the counter supplements should not cause hair loss. The steroid factor from taking natural supplement is hypothetical. You could be just expressing your genetic pattern for your age (a bit late for a 55 year old).

On August 12th, you wrote a post about megasessions suggesting that the Asian patient would probably not be able to to get 6,000 grafts in one session. Please explain your logic.

A Caucasian with an average hair density would have 1250 hairs per square inch found in 625 follicular units which average 2 hairs per follicular unit. A typical Asian patient would have 1000 hairs per square inch found in the same number of follicular units (625) averaging 1.6 hairs per follicular unit.

This particular patient was measured by me to have 500 follicular units in a square inch, thus averaging 1.4 hairs for each follicular unit. In a FUT strip surgery, one would have to remove 12 square inches of scalp (from the strip) to get 6,000 grafts. In other words, to get 6,000 grafts from a strip surgery, the doctor would have to remover 12 square inches of scalp with a width of 1 inch and a length of 12 inches (imagine a school ruler sized area of scalp removed)! This is a very wide strip for very low hair yield of 9600 hairs from the targeted 5,000 follicular units (a typical Caucasian would yield 15,000 hairs) from that same strip size.

The issue of safety is the real issue here. What are the risks of removing a 12 inch by 1 inch strip from the scalp? In the hands of any surgeon, the main risk will relate to (a) wound closure, (b) wound healing, and (c) scalp necrosis. In some hands, this type of surgery might work when good judgments are used. All of these are huge risk categories for the patient and most of these complications come with significant infection that sets in after the surgery. I remember one patient who had a strip taken that was too wide. He suffered from Scalp Necrosis

The first time I saw him was about a month following the strip transplant. He presented with active necrosis and an infection of the wound. As he healed and the infection was controlled, he developed a very wide scar. With the help of Dr. Kabaker (Oakland Surgeon) and we put in a balloon tissue expander into his head and after 10 weeks of constantly inflating the balloon, we removed the scar successfully. He was lucky as his infected scalp could have killed him. The scar he ended up with was minimal. He was very grateful. I remember another patient who came to see me 6 months following his second session of FUE, bringing his total FUE count to 6700. He had poor growth and loss of much of his donor area hair. The grafts probably were taken too close to each other impacting (I believe) the blood supply to the donor area.

For this Asian patient, his scalp was tight and his donor density was poor. His balding pattern was a Norwood Class 5, which meant that we felt he could not achieve his goals of a full head of hair in one large transplant session.

What is the take-away here? Be careful and do your homework when checking out your doctor for any cosmetic surgical procedure. If something sounds too good to be true, get a second opinion. We are talking about not only your looks for the rest of your life, but possibly your life. This is true about any elective surgical procedure and hair transplantation is just one of the examples which I defined here.

Bloomberg News (8/13, French, Basak) reports that according to the National Institute of Mental Health, symptoms of depression “vary and can include feelings of hopelessness, extreme anxiety, appetite changes, insomnia or excessive sleeping, and suicide risk.” Sadly, “just half of Americans diagnosed with major depression are treated and only 20 percent are cared for according to practice guidelines, according to the National Institutes of Health.” ….. It “affects rich people, it affects poor people, it affects people across the spectrum.”

We see a very high suicide rate in the military and in teenagers, young people who have stress that they can’t handle. Most people know of someone or some family member where suicide occurred, a sad statement on how we recognize and manage this problem. In my 20+ years as a hair restoration surgeon, I’ve seen patients with depression who look to cosmetic surgery for the wrong reasons (to cure their depression). I can remember one patient who was scheduled for a hair transplant and I cancelled his surgery (on the morning he was to have surgery) and referred him to see a psychiatrist that same day! It was the right choice for him and he was treated. (He never ended up with a hair transplant surgery as it would have been the wrong choice.)

I also remember two patients who committed suicide because of depression where balding was the tip of the iceberg. I recognized one of these two individuals as severely depressed, and tried to get involved in his life by recommending appropriate treatment, constant follow-up and I had discussions with his family about the problem. This second patient was from the mid-west so meeting with him regularly was out of the questions and my many phone conversations just showed caring. After he committed suicide, his mother called me to thank me for my support, but clearly not enough was done for him. It was a very sad experience for me, a frustrating one, as I felt helpless.

Do you agree that in some persons, despite having DHT levels high since 16, but balding only started in 40’s, a plausible explanation would be that their androgenetic receptors was closed and only opened years later ?

Some people keep hair thick, strong hair, but suddenly after 38 years old or 40 years old, start to get miniaturization and became bald in 10 years. If they had androgenetic receptors open since the 17, they would have a balding progression since that age, and not suddenly start at 37 or 40, when DHT levels are not high as in 20 years old. Some doctors say androgenetic receptor have a date to open, genetically programmed. Otherwise balding would start in 15 years old. Some kids of 12 years old have balding, like some small crown loss. It’s rare, but there are. I suppose their receptors were prematurely open and even the pre-teen DHT levels were enough to start balding.

I don’t know. We can all theorize. Every hair has a biologic clock with regard to genetic hair loss. Medicine is not an exact science. My explanation has been rather simple. It’s genetics! If you have genetic hair loss, you could have started the balding process late in life. Ultimately, it doesn’t matter what receptors open or close or what your DHT levels are. It might be interesting to study, but I’m not sure that these things make a difference in the grand scheme of treating your hair loss.

Some people smoke all their lives and never get lung cancer. Some people live to be 114 years old (my great grandmother) without hair loss. Some people go bald at 40 or 50 years old. It’s the mystery of life. I haven’t figured it out yet.

I just met with a Asian man with very low density, even for an Asian. He was considering the different harvesting techniques FUE vs strip surgery. He met with other doctors who represented that they could transplant 4000-5000 grafts in a single strip session and 3000 FUEs in a single FUE session. This poor man was confused when I suggested that his yield would be less than 2000 grafts with a strip surgery.

There is a great deal of hype on the Internet that people need to have a single large session of 6,000 grafts to get coverage and that is preferable to 3000 grafts in each of two sessions. I would agree if I did not know better. First let me state my qualifications for what I am about to say. I was the first doctor in the world to do 2000 grafts, then 3000 grafts than 4000 grafts in a single session back in 1992-4 and I have been doing larger sessions longer than anyone in the world starting back in 1992. I was using follicular units in large sessions before most of the doctors heard of the follicular unit, let alone the megasession. That would make me an expert on the subject of large sessions hair transplants and I doubt that anyone would challenge my expertise (see references below from prior to 1995). Add to that the fact that I practically invented the large session of small grafts. You may not know my training in surgery, but I am a board certified general surgeon who did everything from war surgery (in the Vietnam war) to extensive trauma, vascular and cancer surgery. That would make me more than qualified to perform a large session harvesting technique for modern hair transplantation.

Of course, if I could harvest 6000 grafts in a single session safely, I would do it more often. I have always had the supportive staff to carry out this type of surgery. But as safety is my guide in all circumstances, my judgments tell me often that taking out a strip which would yield 12,000 hairs (6,000 grafts) is often dangerous and would put the patient at risk to develop some complication. Please note that I clarified that a 6,000 graft harvest should yield about 12,000 hairs, so if a 6,000 graft harvest yielded substantially less than 12,000 hairs, then I might start thinking that smaller grafts were produced by sub-dividing follicular units which is a sin in my ‘ethical’ book. What makes it a sin is that as the fees are directly related to graft counts, sub-dividing follicular units as a routine accomplish two things (1) it raises the surgeon’s fee, and (2) they damage follicular units which tends to produce decreased hair survival.

A hair is not a hair. Fine hair has low bulk and when someone states that they can completely cover a bald man’s head with 6,000 fine hair grafts referencing a ‘gorilla’ result, they are just plain lying. Dr. Feelgood may market his god-like qualities, but Dr. Feelgood just ‘ain’t’ god.

I get rattled when someone tells me through the various internet forums that I should have given someone 6,000 grafts to manage his bald head and that if it was done by Dr. Feelgood, everyone knows that Dr. Feelgood always achieves high graft counts (no mention of the hair count of course). I would ask two questions, (1) what are the hair counts in such large sessions as a matter of routine, and (2) what do the donor wounds look like as a matter of routine. I know more than most what is possible and what is safe, and I know what is not. I use my judgment to ascertain safety and I really don’t believe for one minute that Dr. Feelgood would get 6,000 grafts (12,000 hairs) when I could only get 3,000 grafts (6,000 hairs), never, never, never. If a graft count in the 5000-6000 range is possible, I do them with the agreement of my patient.

The forum chat ‘folks’ who are not knowledgeable about the subtleties of a safe strip harvest and who believe in the marketing hype of some of the internet doctors can talk from their ‘armchair’ all they want. Either my patients are not typical and have tighter scalps and lower densities than Dr. Feelgood’s patients, or some of the doctors who claim these high numbers routinely are either lying to push up the numbers and claim a ‘mighty’ superman deed rewarded (of course) by making more money, or I am a monkey’s uncle.

Published References from prior to 1995 when almost every hair transplant doctor in the field was doing small sessions of large plugs:
# Rassman, W.R.; Bernstein, R.M. One of our greatest problems – lowballing! Hair Transplant Forum. 2(6); 1992.
# Rassman, W.R.; Pomerantz, M.A. The Art and Science of Minigrafting. International Journal of Aesthetic and Restorative Surgery. 1(1): 27-36; 1993.
# Rassman, W.R. A buyers guide to hair transplantation. Los Angeles, CA: NHI; 1993.
# Rassman, W.R. The minigrafts’ revolution, can we keep up ethically? Publication Journal of Cosmetic Surgery.
# Rassman, W.R. Everything you wanted to know about hair transplantation but were afraid to ask. Los Angeles, CA: NHI; 1993.
# Rassman, W.R. The fast track option: a common sense approach to hair transplantation. Los Angeles, CA: NHI; 1994.
# Rassman, W.R. Megasessions: Dense Packing. Hair Transplant Forum 4(3); 1994
# Rassman, W.R Concern about quality. Hair Transplant Forum 4(4); 1994
# Bernstein, R.M.; Rassman, W.R.; Szaniawski, W.; Halperin, A. Follicular transplantation. International Journal of Aesthetic and Restorative Surgery. 3:119-32; 1995.
# Rassman, W.R.; Carson, S. Micrografting in extensive quantities, the ideal hair restoration procedure. Publication to Journal of Dermatology, Surgery and Oncology, 1995
# Rassman, W.R. Follicular Unit Transplantation Megassessions, Hair Transplant Forum Intl. 5(5); 1995

“Testosterone replacements can increase the risk of serious heart and blood vessel problems, Health Canada says.”

The article is to the point and lists all of the common products that can kill you silently. I see patients every week who are taking testosterone supplements for a variety of reasons including: They test their testosterone levels and find it on the low side, they are weight lifters and think that they will be able to lift more weight, or they have erectile dysfunction and think that testosterone will cause them to have better sexual performance.

Remember Jim Fixx, the famous author of The Complete Book of Running who in his mid-thirties was 220 lbs and smoked 2 packs of cigarettes per day. He pioneered the role of exercise in keeping healthy, but died at the age of 52 of heart disease while Jack LaLanne, who died at the age of 96, added good healthy eating to his daily exercise routine. Women were complacent for years believing that their hormones protected them from heart disease (although some did take testosterone for better sexual performance), but for women who do not practice good eating and exercise, found that they were not immune from heart disease and may even be more prone to sudden death from heart attacks. Ask yourself, if you don’t believe in diet and daily good exercise routines, are you ready to die for that belief? As a side note to this article, when you take testosterone, it will accelerate any genetic male pattern balding that you might have.

This patient was a victim of a bad surgery and old plug scars. He didn’t have enough hairs to cover the plugs or enough transplanted hairs to cover the top. He was out of options other than wearing hats or a hair piece. SMP helped him with creating a hair line and hiding most of his scars. The photos were taken a few minutes after the SMP so it still looks a bit red.
Hair line and temples are very important part of creating a natural looking hair line. There is no standard “template” you can use. Everyone’s hair line and individual goals are different. Dr. Pak’s artistic background helped create a new hair line. Dr. Pak actually does most of his hair lines free hand much like his portrait sketches. This prevents the all too common helmet head or lego head.

I had 4-5 hair transplant procedures performed between 5-8 years ago. I am not content with my scar revision. I would like to research which is the best method to cover up my scar well enough so that if I were to shave my head completely, the scar would be undetectable. Wouldn’t putting enough FUE’s in the former donor scar area be the right solution? Which doctor would be the most qualified to do this? I am not just looking for any doctor to do this. I would like a doctor who specializes with this procedure, and not someone who kinda knows what he’s doing. Please advise.

Thank you

If you are looking at NHI for a consultation, then please call (800) NEW-HAIR or email hairdoc@newhair.com to set up a consultation.

Or check out this POST

Otherwise scar revision surgery and FUE transplants to the donor area scar is one of many options. Both of these may not work. Scar revisions often only reduce the scar by 50%, if at all and FUE transplants into the scar produces some kinky hair growing out of the scar and really never make it really disappear ‘in the forest of hair’. There is also scalp micropigmentation as a non surgical option. As you correctly state, you should seek out an experienced and qualified doctor (as you should for any surgery).

Dear Doctor –
Is there any chance that a long-ish regimen of antibiotics could interfere with the efficacy of ongoing finasteride treatment?

More broadly, is there any contraindication of commonly used antibiotic scrips and finasteride? Is there any connection of antibiotic Tx to hairloss, in general?

Thanks.

There is no association that I know of with hair loss and chronic antibiotic use with or without finasteride.